Insurance companies that sell short- or long-term disability insurance policies are in business to make a profit. It follows that they are not necessarily there to be benevolent supporters of their policyholders when they struggle with disabling health conditions.
To that end, it is unfortunate that most disability insurers have the same arrows in their quivers – a set of underhanded claim processing tactics used not to reach the right decision on a disability claim, but rather to figure out a way to deny it (or to terminate a claimant already receiving benefits).
Many people never have to deal with a disability insurance claim so are not likely to recognize these tactics. They understandably trust in the insurance claims process. But when things go awry such as by receiving an unexpected denial or always getting the runaround when you try to contact the insurance company, a lawyer is a good idea. (It can also be smart to consult an attorney at the time of completing the paperwork to file the claim but bringing one on board at any stage can still be very helpful.)
Legal counsel who regularly represent short- or long-term insurance claimants should be very familiar with the ins and outs of insurance company denial tactics. Disability lawyers are well equipped to recognize deceptive tactics and to fight against them for their disabled clients.
We previously posted a comprehensive, detailed discussion about several common deceptive delay and denial tactics. Today, we discuss two insurance company tactics involving the use of policy language to deny a claim by misstating what the actual evidence shows to shoehorn it into a basis for denial.
Abusing preexisting condition exclusions
Many disability insurance policies will not pay benefits for medical problems that existed before the policy effective dates within a specified look-back time period. For example, there could be a look-back period of three or six months, or a year within which the disabling condition that is the basis of the claim may not have already existed.
The problem is that insurers often analyze claimants’ medical histories during look-back periods for any symptoms or conditions arguably or tangentially related to the current disabling conditions. However, an insurer must comply with any definition of preexisting condition in the policy. That definition may require, for example, that for a previous condition to disqualify the claimant from current benefits, during the look-back period they must have had a doctor’s diagnosis, sought medical care for the same problem, taken prescription medicine for the same illness or injury or other similar definitional terms.
Or ambiguous policy terms on this topic may allow the insurer to assert its own interpretation in its favor that is not supportive of the claimant.
However, many courts interpreting preexisting condition exclusions require that there be clear and strong connections between the preexisting medical problems and current disabilities. A tenuous link is normally not enough to disqualify a claim. There must be a direct, substantial association between the problems in the look-back period and the current disability for a preexisting condition to be disqualifying.
Misstating a claimant’s job duties
Disability insurance policies usually contain “Own Occupation” provisions, meaning that for a limited time, often for the first two years of benefits, eligibility requires that claimants’ disabling conditions prevent them from performing the substantial and material duties of their jobs. At that point, policies normally require that claimants’ disabilities prevent them from performing any job for which they are qualified.
The tactic disability insurers use to deny claims in this context is to use generalized, vague descriptions of claimants’ jobs that leave out job requirements that are relevant to the ability to work. For example, an accountant’s job may appear to be a sedentary desk job based on work duties largely performed while sitting and using a computer or phone. On this basis, many disability claims could be denied, depending on the illness or injury.
However, a claimant who works in accounting may also have training or travel responsibilities that are too difficult for someone with reduced stamina from a condition like lupus or fibromyalgia, or even from side effects of medication.
How can DI Law Group help?
A delay or denial of a disability claim can be financially devastating. DI Law Group represents long-term care and all disability insurance claimants at every stage of the insurance process. If you have any questions regarding your disability or life insurance claim, our team of attorneys would be happy to provide you with a free consultation. Please contact us at 888-644-2644 or visit our website at www.dilawgroup.com.